The effect of multidimensional exercises on balance, mobility, and fall risk in community-dwelling older adults

Reliability of the dynamic gait index in people with vestibular disorders11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To examine the interrater reliability of the Dynamic Gait Index (DGI) when used with patients with vestibular disorders and with previously published instructions.

DESIGN

Correlational study.

SETTING

Outpatient physical therapy clinic.

PARTICIPANTS

Subjects included 30 patients (age range, 27-88y) with vestibular disorders, who were referred for vestibular rehabilitation.

INTERVENTIONS

Subjects' performance on the DGI was concurrently rated by 2 physical therapists experienced in vestibular rehabilitation to determine interrater reliability.

MAIN OUTCOME MEASURES

Percentage agreement, kappa statistics, and the ratio of subject variability to total variability were calculated for individual DGI items. Kappa statistics for individual items were averaged to yield a composite kappa score of the DGI. Total DGI scores were evaluated for interrater reliability by using the Spearman rank-order correlation coefficient.

RESULTS

Interrater reliability of individual DGI items varied from poor to excellent based on kappa values (kappa range,.35-1.00). Composite kappa values showed good overall interrater reliability (kappa=.64) of total DGI scores. The Spearman rho demonstrated excellent correlation (r=.95) between total DGI scores given concurrently by the 2 raters.

CONCLUSION

DGI total scores, administered by using the published instructions, showed moderate interrater reliability with subjects with vestibular disorders. The DGI should be used with caution in this population at this time, because of the lack of strong reliability.

Effects of a physical activity program. The study of selected physical abilities among elderly women

This study evaluated the effects of a 12-week exercise program on the physical abilities of 55 sedentary women ages 60 to 75. The variables tested were dynamic balances, muscular endurance, sit and reach flexibility, and muscular coordination. Participants were grouped into three exercise groups (n = 45) and one control group (n = 10). Exercise was performed for 1 hour, once, twice, and three times a week for the three experimental groups. Participants were pre- and post-tested for the selected variables. Significant differences (p < .05) were found between exercise and non-exercise groups. The main effects of the training program were significant for all four variables examined, indicating that even those who participated in an exercise group once a week had a significantly higher levels of physical abilities than the control group. The improvement of the experimental groups was proportional to the frequency of the training program applied.

Achieving recruitment goals through community partnerships: the SENIOR Project

This article discusses the process of developing collaborative relationships for a community-based health promotion project. A partnership was established among the university, the city where the intervention took place, and the community senior center. A community advisory board was created to identify the strengths, diversity, and needs of each partner. The community advisory board guided the partnership to recruit 1,277 older adults to participate in the intervention study. A sample was deemed representative after comparison with Census 2000 data, with gender and educational attainment being similar.

Changes in postural stability in women aged 20 to 80 years

BACKGROUND

A study of postural stability was undertaken to identify the relationship between vision and support surface across age decades. Understanding when reliance on vision for postural stability emerges and the support conditions contributing to this instability may provide the evidence required to introduce falls-prevention strategies in younger age decades.

METHODS

We measured postural stability in 453 women aged 20 to 80 years using the Balance Master force-plate system while the women performed the modified Clinical Test for the Sensory Interaction and Balance (firm and foam surfaces, eyes open and closed) and the Single-Limb Stance Test (eyes open and closed).

RESULTS

Women in their 60s and 70s were more unstable than younger women in bilateral stance on a firm surface with the eyes closed. This instability was evident from the 50s when a foam surface was introduced and from the 40s when single-limb stance was tested with eyes closed. A further decline in stability was demonstrated for each subsequent decade when the eyes were closed in single-limb stance.

CONCLUSIONS

Age, visual condition, and support surface were significant variables influencing postural stability in women. Reliance on vision for postural stability was evident for women from the 40s when single-limb stance was tested, from the 50s when bilateral stance on foam was tested, and from the 60s when a firm surface was used. The cause(s) of this decline in stability requires further investigation, and screening for postural instability between the ages of 40 and 60 is advocated.

Quantitative assessment of the stops walking while talking test in the elderly

OBJECTIVE

To examine whether trunk sway and walking speed differ between elderly "stoppers" and "nonstoppers" during a shorter version of the stops walking while talking (SWWT) test-an observational assessment of impaired dual-task performance-and during a normal walking trial.

DESIGN

The original SWWT test was administered on the way to the test room (over a distance of 150m). Then, subjects were asked to walk 2 trials of 8m while wearing a trunk sway measuring device strapped firmly to their lower back. For the first 8-m trial, no questions were asked (control trial). During the second 8-m trial, subjects were asked an easy question (What is your age?) after walking 2m.

SETTING

Long-stay geriatric care unit in Switzerland.

PARTICIPANTS

Seventeen institutionalized elderly (16 women, 1 man; mean age, 86.3y; range, 79-93y). Subjects had to be able to walk at least 150m and to understand simple questions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The amplitude of trunk sway angle and angular velocity in the forward-backward (pitch) and side-to-side (roll) directions and the duration of each trial were compared between the two 8-m walking trials with and without a question among subjects who did and did not come to a complete stop.

RESULTS

In the original SWWT test, 4 persons stopped walking while talking, compared with 8 persons who stopped in the short (8-m) walking trial when a question was asked. Persons who stopped during the 8-m trial when a question was asked had significantly longer walking durations (by 19s) and larger trunk roll angular displacements (by 5.5 degrees ) during trials, both with and without a question. For both stoppers and nonstoppers, duration was longer during the trial when a question was asked.

CONCLUSION

A fixed and brief walking distance, coupled with a single sudden question, provided an effective method of identifying subjects who stop walking while talking. These subjects are those who have slower walking speeds and more unstable trunk control in the roll plane even under normal walking conditions. Our findings support the predictive capabilities of a brief SWWT test for the unstable and fall-prone elderly, as well as the usefulness of objective trunk sway measures to identify gait instabilities.

Use of clinical and impairment-based tests to predict falls by community-dwelling older adults

BACKGROUND AND PURPOSE

Few tests have been found to be strongly predictive of falls in community-dwelling older adults. The purpose of this study was to determine whether data from 5 balance tests-combined with data regarding fall history, number of medications, dizziness, visual problems, use of an assistive device, physical activity level, sex, and age-could predict falls in community-dwelling older adults who were independent.

SUBJECTS

Ninety-nine community-dwelling older adults aged 65 to 90 years (X =74.02, SD=5.64) were tested.

METHODS

Subjects were tracked for falls over a 1-year period following testing. Impairment-based tests, which are tests that attempt to specifically identify which sensory systems are impaired or how motor control is impaired (eg, speed, accuracy of movement), were the Modified Clinical Tests of Sensory Interaction for Balance (Modified CTSIB) and the 100% Limits of Stability Test, both of which were done on the Balance Master 6.1. Performance-based tests, which are functional tests that identify functional limitations without necessarily identifying their causes, were the Berg Balance Scale, the Timed "Up Go" Test, and the Dynamic Gait Index. Demographic and health data included age, sex, number of medications, physical activity level, presence of dizziness, vision problems, and history of falls over the previous year. Logistic regression was used to determine which combinations of data from balance tests, demographics, and health factors were predictive of falls.

RESULTS

Two models-(1) the "standing on a firm surface with eyes closed" (FEC) condition of the Modified CTSIB and (2) the FEC combined with age and sex-were predictive of falls, but predicted only 1 and 2 subjects who were at risk for falling, respectively, out of 20 people who were at risk for falling.

DISCUSSION AND CONCLUSION

Five balance tests combined with health and demographic factors did not predict falls in a sample of community-dwelling older adults who were active and independent.

Progressive resistance strength training for physical disability in older people

BACKGROUND

Muscle weakness in old age, is associated with physical disability and an increased risk of falls. Progressive resistance strength (PRT) training exercises (i.e. movements performed against a specific external force that is regularly increased during training) are designed to increase strength in older people.

OBJECTIVES

To assess the effect of PRT on measures of physical disability, functional limitation and impairment in older people, and identify adverse events.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialized register (to August 2002), CENTRAL/CCTR (The Cochrane Library Issue 2, 2002), MEDLINE (1966 to February 1, 2002), EMBASE (1980 to February 1, 2002), CINAHL (1982 to February 1, 2002), Sports Discus (1948 to February 1, 2002), PEDro - The Physiotherapy Evidence Database (accessed February 1, 2002) and Digital Dissertations (accessed February 1, 2002). We also searched reference lists of articles, reviewed conference abstracts and contacted authors.

SELECTION CRITERIA

Randomised trials of PRT alone for older people (i.e. mean age of 60 or over) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Weighted mean differences (WMD) were obtained using fixed or random effect models as appropriate. When measures with different units were pooled, standardised mean differences (SMD) were calculated. Relative risks were calculated for dichotomous outcomes.

MAIN RESULTS

Sixty-six trials with 3783 participants were included. Most studies were small and of poor quality. PRT had a large positive effect on strength (41 trials, 1955 participants), but there was statistical heterogeneity that was not explained by differences in study quality, participant characteristics or the exercise program. Some functional limitation measures showed modest improvements (i.e. gait speed, 14 trials, 798 participants, WMD 0.07 m/s, 95% CI 0.04 to 0.09). However, there was no evidence that PRT had an effect on physical disability when activity measures or health related quality of life measures (HRQOL) were assessed (10 trials, 798 participants, SMD 0.01, 95% CI -0.14 to 0.16 ). Adverse events were poorly recorded, but musculoskeletal injuries were detected in most of the studies that prospectively defined and monitored these events.

REVIEWER'S CONCLUSIONS

PRT appears to be an effective intervention to increase strength in older people and has a positive effect on some functional limitations. However, the effect of this intervention on more substantive outcomes such as measures of disability or HRQOL remains unclear. It is difficult to determine the balance of risks and benefits of PRT because adverse events have generally been poorly collected and recorded.

Interventions for preventing falls in elderly people

BACKGROUND

Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group specialised register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field.

SELECTION CRITERIA

Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate.

MAIN RESULTS

Sixty two trials involving 21,668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness: Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants). Interventions unlikely to be beneficial: Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

REVIEWER'S CONCLUSIONS

Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Age-related differences in lower extremity power after support surface perturbations

OBJECTIVES

The purpose of this study was to examine a comprehensive measure relating to the ability to generate, absorb, and transfer mechanical energy introduced by a perturbation. It was hypothesized that this measure would reveal age-related differences leading to different balance recovery responses (i.e., feet-in-place and compensatory step).

DESIGN

Cross-sectional, descriptive study.

SETTING

The Motor Control Laboratory at the University of Oregon.

PARTICIPANTS

Eighteen younger (aged 18-35) and 21 older (aged 65-85) women received forward and backward support surface translations of varying amplitudes and velocities.

MEASUREMENTS

Lower extremity peak positive joint power and peak negative muscle power were examined at the largest perturbation in which a feet-in-place response was used and the subsequent perturbation where a step occurred. Peak positive joint power depicts the maximum rate of passive transfer of energy into a segment and is indicative of the maximum destabilization of that segment. Peak negative muscle power is the maximum rate of energy absorption by muscle, which reduces the effect of the perturbation on the segment.

RESULTS

After a backward perturbation, there was a significant main effect of age for muscle power and a significant main effect of response type for joint power. For the forward condition, there was a significant main effect of response type for muscle power only.

CONCLUSIONS

The mechanical reason for the emergence of the compensatory step after support-surface perturbations is clear; the feet-in-place response is energetically more demanding than the compensatory step. The energy analysis suggests a mechanical basis as one reason for older adults' reliance on the compensatory step: older adult muscles absorb less energy. The results of this study also highlight the importance of the proximal knee and hip musculature versus the distal ankle musculature.

A randomized controlled trial comparing 2 instructional approaches to home exercise instruction following arthroscopic full-thickness rotator cuff repair surgery

STUDY DESIGN

A prospective unblinded randomized clinical trial.

OBJECTIVES

To compare the effectiveness of 2 types of home program instruction, videotape versus personal instruction by a physical therapist, on subjective outcomes and exercise compliance following arthroscopic repair of a full-thickness rotator cuff tear.

BACKGROUND

Advances in orthopedic surgery and rehabilitation have placed increased emphasis on home exercise programs. Therefore, assessing the effectiveness of different methods of home program instruction is important.

METHODS AND MEASURES

Patients who consented to undergo surgical repair were randomly assigned to either a videotape or personal instruction group. A self-reported compliance log categorized subjects as fully compliant, partially compliant, or noncompliant. The Shoulder Pain and Disability Index and the University of Pennsylvania Shoulder Scale scores were obtained from subjects preoperatively and at 12, 24, and 52 weeks postoperatively. The null hypotheses that neither group would have better outcomes as measured by 2 shoulder outcome scales at any level of compliance over 4 levels of time, were assessed by 2 separate 2x3x4 multiple analyses of variances (MANOVAs), 1 for each outcome measure (alpha = 0.025).

RESULTS

Neither MANOVA was significant and the null hypotheses were not rejected. The main effect of time (number of weeks postsurgery) was significant across all time intervals for both outcome measures (P < 0.0005).

CONCLUSIONS

With a therapist available for questions, patients who utilized the videotape method for their home program instruction had self-reported outcomes equal to patients instructed in their home program personally by a physical therapist. Self-reported compliance with the rehabilitation program had little effect on the outcomes.

Perception of unsteadiness in patients with dizziness: association with handicap and imbalance

Dizziness is a common problem in patients seeking medical help and is often associated with imbalance and handicap. This study aimed to reveal whether the perception of unsteadiness could be an indication of greater imbalance and handicap in these patients. Patients with dizziness were categorized into two groups, steady patients (n = 15) and unsteady patients (n = 23), based on the presence or absence of self-perceived unsteadiness. The level of self-perceived handicap was evaluated by the Dizziness Handicap Inventory. Static balance ability was evaluated using a force platform and the center of pressure motion was calculated during various quiet standing conditions. Dynamic balance ability was evaluated by the functional forward reach test and Dynamic Gait Index. All the patients also went through isometric strength tests of the lower extremities. It was found that all patients reported themselves to be handicapped by dizziness. Patients who perceived themselves to be unsteady had greater handicap and poorer static standing, but did not differ from the steady patients in regard to muscle strength or functional balance tests. Thus, self- perceived unsteadiness was associated with greater handicap and poorer static balance in dizzy patients. In clinical management of these patients, special attention should be paid to balance and handicap.

Exercise to prevent and treat functional disability

There are myriad ways in which optimal levels of physical activity over the course of the life span could potentially contribute to the prevention of functional disability in old age. These include direct effects of exercise to maximize physiologic capacity and prevent or delay the onset of disability-related conditions and more indirect effects, such as the modulation of psychosocial factors important in the expression of disability. Epidemiologic studies strongly suggest that functional disability is inversely related to physical activity level or physical fitness in various domains. Experimental studies confirm the benefits of exercise on correlates of disability, such as impairments of muscle strength or performance-based tests of functional limitations. However, the evidence that exercise can actually prevent disability in the long-term is not yet established by data from randomized clinical trials in the general population. Secondary prevention of disability in frail elders has been shown in a few trials. The available evidence, however, suggests that a rational exercise prescription for the prevention and treatment of disability at this time should include promotion of a physically active lifestyle and specific exercises targeting aerobic capacity, strength, and balance. Differential emphasis on specific elements of this prescription may be necessary and appropriate, depending on the etiology of the disability in specific cohorts, severity of physical impairments and functional limitations, and other individual characteristics relevant to exercise feasibility, safety, and efficacy.

Gait performance in dementia: the effects of a 6-week resistance training program in an adult day-care setting

BACKGROUND

Age-related declines in balance and muscle power are largely responsible for the changes in the various components of gait performance among elderly people. But these can often be remedied with strength training. People with cognitive impairment frequently demonstrate impaired gait, putting them at increased risks for falls and serious injury.

OBJECTIVES

This paper reports on the effects of a six-week pilot study of moderate intensity strength training on the gait of elderly individuals with dementia who attend a day-care center.

METHODS

Twenty-six adults (23 female, three male), age = 79.2 +/- 6.6 years, completed the study. Each subject completed a baseline assessment of lower extremity strength and gait. Gait was evaluated using free- and fast-gait speed over a 6-meter course, the Tinetti-Gait Assessment scale, the 'Timed-Up-and-Go', and the Gait Assessment Rating Scale (GARS). The intervention consisted of moderate-intensity progressive resistance lower extremity exercise using Theraband, for two to three sessions per week over the six weeks. Post-intervention assessment of strength and gait was repeated at the completion of the sixth week. Multiple paired t-tests were calculated for each outcome measure.

RESULTS

The baseline assessment of gait suggests a high degree of frailty and risk for falls in the sample. Although post-intervention scores reflected improvement on all gait measures, the only statistically significant change observed was in fast-gait time.

CONCLUSION

A six-week resistance training program proved to be of insufficient duration, intensity or specificity to produce significant change in gait outcome measures, with the exception of fast speed gait.

Postural muscle responses following changing balance threats in young, stable older, and unstable older adults

The authors determined the postural muscle response to support surface perturbations, in relation to aging and level of stability of 16 young adults and 32 older adults who were classified into stable (SOA) and unstable (UOA) groups on the basis of their functional balance abilities. Forward and backward support surface translations of various amplitudes and velocities were used so that postural responses of the standing adults could be elicited. The thigh and leg postural muscle responses were recorded with surface electromyography (EMG). The older groups had significantly longer onset latency in the anterior postural muscles, smaller integrated EMG in the posterior muscles, and greater extent of integrated EMG attenuation over time. The UOA showed longer onset latency in the gastrocnemius following slow backward perturbation and used a greater percentage of the functional capacity of the gastrocnemius muscle than the SOA did. Those findings indicate that the SOA and UOA had limited ability to adapt to changing balance threats; the UOA were more limited than the SOA. When designing balance training programs, therefore, therapists should consider the adult's level of functional stability.

Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds

BACKGROUND AND PURPOSE

The interpretation of patient scores on clinical tests of physical mobility is limited by a lack of data describing the range of performance among people without disabilities. The purpose of this study was to provide data for 4 common clinical tests in a sample of community-dwelling older adults.

SUBJECTS

Ninety-six community-dwelling elderly people (61-89 years of age) with independent functioning performed 4 clinical tests.

METHODS

Data were collected on the Six-Minute Walk Test (6MW), Berg Balance Scale (BBS), and Timed Up & Go Test (TUG) and during comfortable- and fast-speed walking (CGS and FGS). Intraclass correlation coefficients (ICCs) were used to determine the test-retest reliability for the 6MW, TUG, CGS, and FGS measurements. Data were analyzed by gender and age (60-69, 70-79, and 80-89 years) cohorts, similar to previous studies. Means, standard deviations, and 95% confidence intervals for each measurement were calculated for each cohort.

RESULTS

The 6MW, TUG, CGS, and FGS measurements showed high test-retest reliability (ICC [2,1]=.95-.97). Mean test scores showed a trend of age-related declines for the 6MW, BBS, TUG, CGS, and FGS for both male and female subjects.

DISCUSSION AND CONCLUSION

Preliminary descriptive data suggest that physical therapists should use age-related data when interpreting patient data obtained for the 6MW, BBS, TUG, CGS and FGS. Further data on these clinical tests with larger sample sizes are needed to serve as a reference for patient comparisons.

Gait, lower extremity strength, and self-assessed mobility after hip arthroplasty

BACKGROUND

Rehabilitation services after hip arthroplasty (HA) usually occur in the first 6 months following surgery. Reports in the literature suggest that 9 months to several years after HA surgery, patients are generally satisfied with pain relief. However, many express dissatisfaction with their ability to perform domestic and social activities. Reduced walking ability and long-term lower extremity (LE) muscle weakness may contribute to decreased mobility. The purpose of this study was to compare the within-group LE muscle strength, gait, and self-assessed functional mobility in adults 9 months to 6 years after HA surgery to age- and gender-matched controls.

METHODS

Thirty subjects (15 HA and 15 control) were studied. LE muscle strength was assessed using the Spark handheld dynamometer. Gait parameters were measured using the GAITMAT II, and self-assessed mobility was evaluated using the hip-rating questionnaire.

RESULTS

The HA group walked significantly more slowly than the control group at maximum walking speed. The operative LE of the HA group had less muscle strength than the nonoperative LE, and the hip abductors were the most affected muscle group in that LE. The HA group scored lower in the domains of impact, pain, and function on the hip-rating questionnaire.

CONCLUSION

Because of long-term residual impairments and disabilities noted after HA surgery, intervention beyond the initial post-surgical rehabilitation is needed.

A meta-analysis of fall prevention programs for the elderly: how effective are they?

BACKGROUND

Although fall prevention studies for the elderly have been reported, there is a paucity of work summarizing the effectiveness of these interventions.

OBJECTIVES

The research question that guided this study was: 'What are the effects of fall prevention programs on the proportion of falls in the elderly?"

METHOD

Meta-analysis was employed to summarize findings of intervention studies of fall prevention in the elderly involving a comparison group and a quantifiable outcome. Studies were reviewed by two of the authors with the eligibility criteria in mind. Studies were then coded and an inter-rater reliability check was performed.

RESULTS

The overall mean weighted effect size for the 12 studies included in the meta-analysis was .0779 (Z = 5.03, p < .001). For fall prevention intervention types, exercise alone had a mean weighted effect size of .0220 (Z = .5303, p > .5), exercise and risk modification had a mean weighted effect size of .0687 (Z = 3.41, p < .001), and comprehensive risk assessment intervention studies had an effect size of .1231 (Z = 3.97, p < .001). The mean weighted effect size size for community-based studies was .0972 (Z = 5.37, p < .001) and for institution-based studies was .0237 (Z = .7822, p = .22). Time to outcome measure analyses revealed that the mean weighted effect size for studies measuring proportion of falls at 12 months was .0905 (Z = 5.43, p < .001), and those measuring at four months or less was -.0972 (Z = -.005, p > .50).

CONCLUSIONS

The results of this meta-analysis indicate that there was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fall prevention interventions. Additional intervention studies need to be conducted in the elderly population with a goal of preventing falls.

Effect of a physical therapeutic intervention for balance problems in the elderly: a single-blind, randomized, controlled multicentre trial

OBJECTIVE

To establish the effect of a short, individualized exercise programme on balance dysfunction in the elderly.

DESIGN

A single-blind, randomized, controlled, multicentre trial.

SETTING

Physical and recreational therapy departments from two rehabilitation centres.

PARTICIPANTS

Ninety-four subjects of >75 years with functional balance problems living independently or in a residential care facility. Seventy-seven subjects completed the intervention period and four-week follow-up. At a one-year follow-up 49 subjects were evaluated on balance functioning.

INTERVENTIONS

Twelve sessions of an individualized balance training programme (experimental group) or 12 sessions of an individualized extra attention programme (control group) given in 4-6 weeks.

MAIN OUTCOME MEASURES

Berg Balance Scale and the Dynamic Gait Index to establish balance functioning, a visual analogue scale to establish fear of falling in daily life and the Hospital Anxiety Depression Scale to verify feelings of anxiety and depression.

RESULTS

Subjects in the experimental group improved significantly more on the Berg Balance Scale and the Dynamic Gait Index than those in the control group (p f 0.001, p f 0.001, respectively). However the effect disappeared at a one-year follow-up on the Berg Balance Scale. No prognostic factors could be identified to determine who would benefit most from the individualized exercise programme. Results on the other response variables revealed no effect of the intervention.

CONCLUSION

A short individualized exercise programme can improve functional balance in people aged 75 years and older. This improvement was maintained at least for one month but had worn off by one year.

Detecting change in patients with stroke using the Berg Balance Scale

The Berg Balance Scale (BBS) was designed to help determine change in functional standing balance over time. The purpose of this paper was to estimate the minimum detectable change score (MDC) using the standard error of measure (SEM), thereby providing a means to decide if genuine change had occurred. Calculation of the agreement regarding the presence of change as determined by the MDC and clinicians' perceptions was performed to give an indication of the validity of this criterion value. Forty-eight subjects who were receiving inpatient rehabilitation after stroke were assessed on consecutive days by two raters using the BBS. The MDC analysis suggests that a change of +/- 6 BBS points is necessary to be 90% confident of genuine change. Only 25/45 subjects showed agreement between the statistically derived presence of change and clinicians' perceptions of change. The lack of agreement may relate to the validity of the SEM/MDC methodology to determine the criterion BBS value, the heterogeneity of the subjects, or the use of clinician gestalt impressions of change.

Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence

Falls are a major source of death and injury in elderly people. For example, they cause 90% of hip fractures and the current cost of hip fractures in the US is estimated to be about 10 billion dollars. Age-related changes in the physiological systems (somatosensory, vestibular and visual) which contribute to the maintenance of balance are well documented in older adults. These changes coupled with age-related changes in muscle and bone are likely to contribute to an increased risk of falls in this population. The integrated rehabilitation-based model of fall risk factors reveals multiple sites for interventions that may reverse fall risk factors. Regular exercise may be one way of preventing falls and fall-related fractures. The evidence for this contention comes from a variety of sources. On the basis of 9 randomised controlled studies conducted since 1996, exercise appears to be a useful tool in fall prevention in older adults, significantly reducing the incidence of falls compared with control groups. However, current limitations such as inconsistencies in the measurement of key dependent and independent variables do not, at present, permit a meta-analysis of intervention trials. Further investigation, using trials designed with the current limitations in mind, is necessary to establish the optimum exercise programme to maximise fall prevention in older adults.

Effects of balance training in elderly people with nonperipheral vertigo and unsteadiness

OBJECTIVE

To evaluate the effect of balance training in group in elderly people with nonperipheral vertigo and unsteadiness.

DESIGN

Randomized controlled study.

SETTING

Ear-, nose- and throat department, University Hospital, Sweden.

SUBJECTS

Twenty-three elderly subjects with nonperipheral vertigo and/or unsteadiness randomized into training group and control group.

INTERVENTION

The training group attended balance training in group twice a week for eight weeks.

MAIN OUTCOME MEASURES

Timed static balance tests, walking tests and six sensory organization tests on EquiTest dynamic posturography were performed before and after the training period. Besides, the patients estimated their vertigo and unsteadiness on a visual analogue scale (VAS) before and after the training period.

RESULTS

The training group improved significantly in standing on one leg with eyes open, walking forward on a line, walking speed, in three out of six tests on dynamic posturography and estimated less vertigo and unsteadiness measured with VAS. No changes were seen in the control group.

CONCLUSION

Balance training in elderly people with nonperipheral vertigo and unsteadiness seems to improve both objective and perceived balance.

Mechanical energy analysis identifies compensatory strategies in disabled elders' gait

Current concepts in disablement emphasize the importance of identifying mobility impairments in aging humans to enable timely intervention and, ultimately, prevent disability. Because mobility impairments are likely to result in compensatory movement strategies, recognizing and understanding those strategies may be critical in designing effective interventions for preventing disability. We sought to determine if mechanical energy methods are useful for identifying and understanding lower extremity compensatory movement strategies due to disabilities. Aleshinski's method was used to compute mechanical energy expenditure (MEE) and mechanical energy compensation (MEC) for the sagittal plane stance leg and low-back joints of healthy elders (HE) and disabled elders (DE) during preferred speed and paced (120 steps min(-1)) gait. DE subjects expended less ankle energy in late-stance and more low-back energy in mid-stance than did the HE subjects. When controlling for walking speed, the difference in ankle MEE disappeared, but mid-stance hip MEE was significantly higher for the DE subjects. Despite increased hip and low-back MEE, the DE subjects compensated hip and low-back muscles greater then HE subjects by increasing energy transferred into the pelvis, particularly when walking faster than their self-selected speed. Increased energy transfers into the pelvis during mid-stance may be a strategy used to assist in advancing and controlling the contralateral limb's swing phase. Increased trunk energy, however, may compromise dynamic stability and increase the risk of falling. We conclude that mechanical energy methods are useful for identifying and understanding compensatory movement strategies in elders with disabilities.

History and mobility exam index to identify community-dwelling elderly persons at risk of falling

BACKGROUND

Falls are common in community-dwelling elderly persons and are a frequent source of morbidity. Simple indices to prospectively stratify people into categories at different fall-risk would be useful to health care practitioners. Our goal was to develop a fall-risk index that discriminated between people at high and low risk of falling.

METHODS

We evaluated the risk of falling over a one-year period in 557 elderly persons (mean age 81.6) living in a retirement community. On the baseline interview, we asked subjects if they had fallen in the previous year and evaluated risk factors in six additional conceptual categories. On the follow-up interview one year later, we again asked subjects if they had fallen in the prior year. We evaluated risk factors in the different conceptual categories and used logistic regression to determine the independent predictors of falling over a one-year period. We used these independent predictors to create a fall-risk index. We compared the ability of a prior falls history with other risk factors and with the combination of a falls history and other risk factors to discriminate fallers from nonfallers.

RESULTS

A fall in the previous year (OR = 2.42, 95% CI = 1.49-3.93), a symptom of either balance difficulty or dizziness (OR = 1.83, 95% CI = 1.16-2.89), or an abnormal mobility exam (OR = 2.64, 95% CI = 1.64-4.26) were independent predictors of falling over the subsequent year. These three risk factors together (c statistic =.71) discriminated fallers from nonfallers better than previous history of falls alone (c statistic =.61) or the symptomatic and exam risk factors alone (c statistic =.68). When combined into a risk index, the three independent risk factors stratify people into groups whose risk for falling over the subsequent year ranges from 10% to 51%.

CONCLUSION

A history of falling over the prior year, a risk factor that can be obtained from a clinical history (balance difficulty or dizziness), and a risk factor that can be obtained from a physical exam (mobility difficulty) stratify people into groups at low and high risk of falling over the subsequent year. This risk index may provide a simple method of assessing fall risk in community-dwelling elderly persons. However, it requires validation in other subjects before it can be recommended for widespread use.

Reduced hip extension during walking: healthy elderly and fallers versus young adults

OBJECTIVES

To test the hypothesis that reduced hip extension range during walking, representing a limiting impairment of hip tightness, is a consistent dynamic finding that (1) occurs with increased age and (2) is exaggerated in elderly people who fall.

DESIGN

Using a 3-dimensional optoelectronic motion analysis system, we compared full sagittal plane kinematic (lower extremity joint motion, pelvic motion) data during walking between elderly and young adults and between elderly fallers and nonfallers. Comparisons were also performed between comfortable and fast walking speeds within each elderly group.

SETTING

A gait laboratory.

PARTICIPANTS

Twenty-three healthy elderly subjects, 16 elderly fallers (otherwise healthy elderly subjects with a history of recurrent falls), and 30 healthy young adult subjects.

MAIN OUTCOME MEASURES

All major peak joint angle and pelvic position values.

RESULTS

Peak hip extension was the only leg joint parameter measured during walking that was both significantly lower in elderly nonfallers and fallers than in young adult subjects and was even lower in elderly fallers compared with nonfallers (all p <.05). Peak hip extension +/- standard deviation during comfortable walking speed averaged 20.4 degrees +/- 4.0 degrees for young adults, 14.3 degrees +/- 4.4 degrees for elderly nonfallers, and 11.1 degrees +/- 4.8 degrees for elderly fallers. Peak hip extension did not significantly improve when elderly subjects walked fast.

CONCLUSION

An isolated and consistent reduction in hip extension during walking in the elderly, which is exaggerated in fallers, implies the presence of functionally significant hip tightness, which may limit walking performance. Overcoming hip tightness with specific stretching exercises is worthy of investigation as a simple intervention to improve walking performance and to prevent falls in the elderly.

Subsystems contributing to the decline in ability to walk: bridging the gap between epidemiology and geriatric practice in the InCHIANTI study

BACKGROUND

Older patients are often referred to geriatricians because of complaints of progressive difficulties in walking. The diagnostic and therapeutic approach to these patients is complex. Multiple physiologic subsystems may influence the ability to walk, and no standard criteria are currently available to establish whether these subsystems are functioning within the normal range. To address this lack of knowledge we conducted the InCHIANTI study.

OBJECTIVE

To identify measures that clinicians can use to understand the causes of walking difficulties in older persons.

DESIGN

A population-based study of persons living in the Chianti geographic area (Tuscany, Italy).

PARTICIPANTS

1,453 persons (age-range 20-102 years; 91.6% of the eligible) selected from city registry of Greve in Chianti and Bagno a Ripoli (Tuscany, Italy), using a multistage sampling method.

MEASUREMENTS

Factors that influence walking ability were classified into six main physiologic subsystems: central nervous system, perceptual system, peripheral nervous system, muscles, bone/joints, and energy production/delivery. Measures of the integrity and functioning of each of these proposed subsystems were identified and administered to all participants.

CONCLUSIONS

Data collected in InCHIANTI will be used to identify the main risk factors that influence loss of the ability to walk in older persons, to define physiologic subsystems that are critical for walking, to select the best measures of their integrity, and to establish critical ranges in these measures that are compatible with "normal" walking ability. The final goal is to translate epidemiological research into a geriatric clinical tool that makes possible more precise diagnosis and more effective treatment in patients with walking dysfunction.

Low-intensity exercise as a modifier of physical frailty in older adults

OBJECTIVE

To examine the effects of a 3-month low-intensity exercise program on physical frailty.

DESIGN

Randomized clinical trial.

SETTING

Regional tertiary-care hospital and academic medical center with an outpatient rehabilitation fitness center.

PARTICIPANTS

Eighty-four physically frail older adults (mean age, 83 +/- 4 yrs).

INTERVENTION

Three-month low-intensity supervised exercise (n = 48) versus unsupervised home-based flexibility activities (n = 36).

MAIN OUTCOME MEASURES

Physical performance test, measures of balance, strength, flexibility, coordination, speed of reaction, peripheral sensation.

RESULTS

Significant improvement was made by the exercise group on our primary indicator of frailty, a physical performance test (PPT) (29 +/- 4 vs 31 +/- 4 out of a possible 36 points), as well as many of the risk factors previously identified as contributors to frailty; eg, reductions in flexibility, strength, gait speed, and poor balance. Although the home exercise control group showed increases in range of motion, the improvements in flexibility did not translate into improvements in physical performance capacity as assessed by the PPT.

CONCLUSIONS

Our results suggest that physical frailty is modifiable with a program of modest activities that can be performed by virtually all older adults. They also indicate that exercise programs consisting primarily of flexibility activities are not likely to reverse or attenuate physical frailty. Although results suggest that frailty is modifiable, it is not likely to be eliminated with exercise, and efforts should be directed toward preventing the condition.

Kinetic alterations independent of walking speed in elderly fallers

OBJECTIVES

To determine if joint kinetic gait alterations in fallers persist when they attempt to walk at a faster speed that is more comparable with nonfallers' comfortable walking speed.

DESIGN

Retrospective, case-control study. Stereophotogrammetric and force platform data were collected.

SETTING

A gait laboratory.

PARTICIPANTS

Sixteen elderly subjects who had at least 2 falls in the last 6 months from an unclear cause and 23 elderly subjects with no history of repeated falls.

MAIN OUTCOME MEASURES

Differences in all major peak joint kinetic (moment and power) values during the gait cycle between elderly nonfallers walking at comfortable speed and elderly fallers walking at (1) comfortable and (2) fast speed.

RESULTS

Statistically significant differences present at both comfortable and fast walking speeds were present in 4 sagittal plane parameters. There was an increase in peak external hip flexion moment in stance, a reduction in peak hip extension moment, a reduction in knee flexion moment in preswing, and a reduction in knee power absorption in preswing.

CONCLUSION

The presence and persistence of 4 specific alterations in sagittal plane joint kinetics at both comfortable and fast walking speeds imply specific intrinsic pattern differences and allow for new insights into the mechanics of gait in elderly people who fall. The presence of these alterations also suggests they may serve as potential identifiable markers to detect those who may be at risk for falls.

An experimental controlled study on postural sway and therapeutic exercise in subjects with low back pain

OBJECTIVES

To describe postural sway and its associations to background factors, low back pain and functional capacity. To evaluate the changes in postural sway after three months of therapeutic exercise in the gym or at home.

DESIGN

A one-year randomized experimental trial evaluated postural sway in three study groups: intensive training, home exercise and control group.

SETTING

Subjects were recruited from seven local occupational health care centres in Central Finland and were examined at Central Finland Hospital by medical doctors. Measurements and therapeutic exercise programmes were carried out in the Research Laboratory of Sport and Health Sciences at Jyväskylä University.

SUBJECTS

Initially, 49 male and 41 female subjects (aged 20-55 years) with nonspecific and subacute low back pain were examined.

MAIN OUTCOME MEASURES

Postural sway using a force platform, the Oswestry Index, as well as a measure of low back pain intensity were measured at the initial stage of the study, directly after interventions, as well as at three and nine months after the interventions.

RESULTS

The background variables were not strongly correlated with postural sway. No changes occurred in the amplitude of sway during the study, but the sway velocity of the home exercise group increased.

CONCLUSIONS

Postural sway measurements with a force platform may be suitable for detecting impairments of balance performance among subjects with pronounced functional or activity limitations and severe low back pain problems. In order to enhance balance performance, specific and customized exercise programmes are required.

Can the control of bodily orientation be significantly improved in a group of older adults with a history of falls?

OBJECTIVE

To determine the short-term effectiveness of a biofeedback-based, computerized intervention that applied the principles of the ecological theory of perception and control of bodily orientation to the rehabilitation of older adults with a history of falling.

PARTICIPANTS

Forty-five older adults (X = 78.5 years) with a history of falls were assigned to either a control (n = 21) or intervention group (n = 24).

DESIGN

A 2 x 2 (Group x Time) mixed factorial design with repeated measures on the second factor.

SETTING

A motor control research laboratory in a university setting.

MEASUREMENT

Impairments in multiple dimensions of balance (i.e., dynamic postural control and sensory organization) were measured before and after an 8-week balance intervention using the 100% Limits of Stability Test and Sensory Organization Test. More functional limitations in balance and/or mobility were measured using two clinical tests: Berg Balance Scale and Timed Up and Go test.

MAIN RESULTS

Repeated measures multivariate analyses and follow-up testing indicated significant improvements in the dynamic balance and sensory integration capabilities in the case of the intervention group only (P < .03). Significant improvements were also observed in the two clinical measures of balance and mobility evaluated before and after the intervention for the intervention group only.

CONCLUSIONS

Theory-driven rehabilitation programs that focus on manipulating individual, task, and environmental constraints concurrently can significantly improve the control of bodily orientation of older adults with a previous history of falls in both static and dynamic action environments. Moreover, the significant improvements in functional performance observed for the intervention group suggest that interventions emphasizing task-specific practice are not the only means by which an older adult's ability to perform daily activities requiring postural control can be improved.

Identification of kinetic differences between fallers and nonfallers in the elderly

Falls are a major cause of decreased mobility and disability in the elderly. Multiple factors are believed to contribute to falling. Among these, gait abnormalities have drawn attention as a possible risk factor. Although previous studies have revealed few differences in gait parameters compared with similar aged controls, it was hypothesized that because of intrinsic differences in balance and motor control, we would observe differences in joint kinetics. In this study, 15 subjects (mean age, 77 +/- 9 yr), who had at least 2 mo of repeated falls from an unclear cause, were evaluated in a gait laboratory and were compared with a control group of 15 subjects (mean age, 75 +/- 5 yr) with no history of falls. Analysis of data demonstrated a significantly greater peak torque in the falls group for the following: hip flexion, hip adduction, knee extension, knee varum, ankle dorsiflexion, and ankle eversion (P < 0.003 in each comparison). Also, ankle plantarflexion torque was significantly decreased in the falls group (P = 0.001). Joint powers showed different absorption at the knee and ankle in the falls group. The discovery of these kinetic differences may provide further insight into the mechanism of falls in the elderly and, more importantly, lead to identifiable markers to detect those who may be susceptible to falls.

The roles of exercise and fall risk reduction in the prevention of osteoporosis

In summary, the optimal model for the prevention of osteoporotic fractures includes maximization and maintenance of bone strength and minimization of trauma. Numerous determinants of each have been identified, but further work to develop preventative strategies based on these determinants remains to be undertaken. Physical activity is a determinant of peak BMD. There also is evidence that activity during growth modulates the external geometry and trabecular architecture, potentially enhancing skeletal strength, while during the adult years activity may reduce age-related bone loss. The magnitude of the effect of a 7% to 8% increase in peak BMD, if maintained through the adult years, could translate to a 1.5-fold reduction in fracture risk. Moreover, in the older population, appropriate forms of exercise could reduce the risk of falling and, thus, further reduce fracture risk. These data must be considered as preliminary in view of the paucity of long-term fracture outcome data from randomized clinical trials. However, current information suggests that the optimal form of exercise to achieve these objectives may vary through life. Vigorous physical activity (including weight-bearing, resistance, and impact components) during childhood may maximize peak BMD. This type of activity seems optimal through the young adult years, but as inevitable age-related degeneration occurs, activity modification to limit the impact component of exercise may become necessary. In the elderly, progressive strength training has been demonstrated to be a safe and effective form of exercise that reduces risk factors for falling and may also enhance BMD. In the frail elderly, activity to improve balance and confidence also may be valuable. Group activities such as Tai Chi may be cost-effective. Precise prescriptions must await the outcome of well-designed, controlled longitudinal studies that include fracture as an outcome. However, increased physical activity seems to be a sensible component of strategies to reduce osteoporotic fracture.

Review of the literature on falls among the elderly

PURPOSE

To review and summarize the literature from nursing, medical, and ancillary fields on falls among the elderly. Major injuries from falls are associated with mortality, especially among the elderly. Researchers indicate that, in many cases, falls can be prevented. A summary of the available literature provides information which can be used to plan interventions.

ORGANIZING FRAMEWORK

Over 100 publications, 1979-1996 related to falls by elderly were reviewed. Descriptive terms used for searching MEDLINE were falls, elderly, and accidents. Literature from several disciplines was reviewed.

FINDINGS

Fall risk can be predetermined and nursing actions can be taken to reduce the occurrence and severity of falls.

CONCLUSIONS

To reduce the deleterious effects of falls in the elderly, knowledge-based practice is essential.